Aim: Three quarters of strokes occur in the region supplied by
the middle cerebral artery. As a consequence, the upper limb will
be affected in a large number of patients. Purpose of the study is to
examine the effectiveness of mirror therapy in rehabilitation of hand
function in sub-acute stroke.

Methodology: An experimental study design, 30 subjects with
sub-acute stroke with impaired hand function randomly allocated 15
subjects into each experimental group and conventional group. Both
groups received conventional physiotherapy. The experimental group
in addition, received Mirror Therapy program of 30 repetition of each
exercises per day for 5 days in a week for 4 weeks (total = 20 sessions).
Hand functions were measured using Upper extremity motor activity
log (UE MAL) and Action research arm test (ARAT) before and after 4
week of intervention.

Results: Results of the study suggested that both the experimental
and conventional group had a significant improvement in hand
function (AROM, functional task with objects, object manipulation),
however experimental group showed significantly more improvement
than conventional group, providing Mirror Therapy with conventional
treatment is more effective than conventional treatment alone.

World Health Organization [WHO; Stroke; 1989]
defines the clinical syndrome of stroke as ‘rapidly developed
clinical signs of focal (or global) distribution of cerebral function
with symptoms lasting more than 24 hours or longer or leading
to death, with no apparent cause other than vascular origin’.

Prevalence rates reported for stroke or CerebroVascular
Accident (CVA) worldwide vary between 500 to 800 per 100,000
population [N.K. Sehi et al 2007] with about 20 million people
suffer from stroke each year; out of that 5 million will die as
a consequences and 15 million will survive with long term
disabilities of varied spectrum. Many surviving stroke patients
will often depends on other people‘s continuous support to
survive.

Stroke is the most common cause of chronic disability
[1]. Of survivors, an estimated one third will be functionally
dependent after 1 year experiencing difficulty with activities of
daily living (ADL), ambulation, speech, and so forth [2]. Cognitive
impairment occurs frequently after stroke, commonly involving
memory, orientation, language, and attention. The presence
of cognitive impairment in patients with stroke has important
functional consequences, independent of the effects of physical
impairment (T K Tatemichi et al 1994).

Recovery of function after stroke may occur, but it is
unclear whether interventions can improve function beyond the
spontaneous process. In particular, recovery of hand function
plateaus in about 1 year, and common knowledge is that the
patient will remain at that level for the rest of his or her life [3,4].
Typically in such situations, upper arm function is better than
that in the hand [5]. An emerging concept in neural plasticity is
that there is competition among body parts for territory in the
brain [6-11].

Several studies have been conducted to examine the
recovery of the hemiplegic arm in stroke patients. Up to 85% of
patients show an initial deficit in the arm. Three to six months
later, problems remain in 55% to 75% of patients [12-15]. While
recovery of arm function is poor in a significant number of
patients. Three quarters of strokes occur in the region supplied
by the middle cerebral artery [16]. As a consequence, the upper
limb will be affected in a large number of patients. Functional
recovery of the arm includes grasping, holding, and manipulating
objects, which requires the recruitment and complex integration
of muscle activity from shoulder to fingers.

Functional brain imaging studies of healthy subjects
suggest that excitability of the primary motor cortex ipsilateral
to a unilateral hand movement is facilitated by viewing a mirror
reflection of the moving hand [17]. Reorganization of motor
functions immediately around the stroke site (ipsilesional) is
likely to be important in motor recovery after stroke, and a
contribution of other brain areas in the affected hemisphere is
also possible. Activation when a subject is doing motor tasks can
also occur in the bilateral inferior parietal area, the supplementary
motor area, and in the premotor cortex. Furthermore, central
adaptations occur in networks controlling the paretic as well as
the nonparetic lower limb after stroke [18].

The aim of this study is to find the effect of mirror
therapy in rehabilitation of hand function in sub-acute stroke.

Methodology

Study Design:
Two group, pre-test post-test structured,
experimental study design. A total of 30 subjects with hemiplegia
due to stroke were randomly selected and were recruited from
physiotherapy department of Swami Vivekananda National
Institute of Rehabilitation Training and those who matched
inclusion and exclusion criteria were randomly assigned to the
two groups.

Inclusion Criteria:
Subjects had first episode of unilateral stroke
with hemiparesis, aged between 35 and 55 year, Brunnstorm
stage between II and IV for upper extremity, Able to understand
and follow simple verbal instruction with no cognitive disorder,
Patient having stroke upto 1 year of post-stroke.

Procedure:
All the stroke persons who were willing to participate,
and the subjects who met the inclusion and exclusion criteria
signed the informed consent. Then subjects were assessed and
randomly allocated into two groups Experimental group and
Conventional therapy group by picking up chits marked 1 and
2. All participants underwent an initial baseline assessment
of Upper Extremity Motor Activity Log (UE MAL) and Action
Research Arm Test (ARAT). Both groups received conventional
physiotherapy [stretching and strengthening exercises, active
range of motion exercises and ADL training (Functional tasks
with objects and object manipulation]. The experimental group in
addition, received Mirror Therapy including forearm supination
and pronation, wrist flexion and extension, finger flexion and
extension, fanning of fingers, counting fingers with conventional
therapy.

Upper Extremity Motor Activity Log (UE MAL): This
instrument is a structured interview intended to examine
how much and how well the subject uses their more-affected
arm outside of the laboratory setting. Participants were asked
standardized questions about the amount of use of their
more-affected arm (Amount Scale or AS) and the quality of
their movement (How Well Scale or HW) during the functional
activities indicated. Score was calculated for both scales by adding
the rating scores for each scale and dividing by the number of
items asked. Inter-test reliability for the 2 MAL scales = .99 and
.96; correlation of the scales of the MAL with the Abilhand Test -
.88 and .71. (Johnson A, Judson L, Morris D, Uswatte G, Taub
E).

Action Research Arm Test (ARAT):
The ARAT is
an observer-rated, performance-based assessment of upper
extremity function and dexterity. It consisted of 19 items designed
to assess four areas of function; grasp, grip, pinch, and gross
movement. Each question was scored on an ordinal scale ranging
from 0 (no movement) to 3 (normal performance of task). Score
ranges from 0 – 57, with lower scores indicating greater level of
impairment. Action research arm test (ARAT) has been found to
have excellent Interrater Reliability (Nijland et al, 2010; Van
der Lee et al, 2001).

During the Mirror therapy patient were seated close
to a table on which a mirror was placed vertically. The involved
hand was placed behind the Mirror and the non-involved hand
in front of the Mirror. During exercise patient looked into the
Mirror, watching the mirror image of non-involved hand. Patients
involved hand was hidden from sight. During the session patient
was instructed to imagine the reflected image as the involved
hand. Patients were also instructed to try to do the same
movements with the paretic hand while they watched only the
mirror image of the non-paretic hand. The group received Mirror
therapy program of 30 repetition of each exercises per day for 5
days in a week for 4 weeks (total = 20 sessions).

Data Collection:
Measurements were taken prior to the beginning
of the treatment (pre-test) and were repeated after completion of
4 weeks (post-test).

Data Analysis:
Analysis was performed using SPSS version 23.0
package.

Data was analyzed using non parametric, Mann-
Whitney U Test to test difference between pre to post change
scores of conventional group with that of the experimental group.

Wilcoxon Signed Rank Sum test is used to test the within
group difference in pre and post intervention scores. 0.05 level of
significance was used for hypothesis testing.

Results

The extent of improvement in MAL (AS) score in
experimental group is more as compared to conventional group
from pre test measurement to post test measurement as depicted

Graph 1: Mean change in MAL (AS) score between groups

Improvement in hand function was significant in both
experimental and conventional groups; however experimental
group showed significant more improvement than conventional
group. Wilcoxon Signed Rank test showed that there was
significant change from pre to post score of MAL (AS) in
conventional group – (p = 0.003, z = -2.936) and in experimental
group (p= 0.001, z = -3.409).

Mann-Whitney U test showed that there is statistically
significant difference in the change score of MAL (AS) between
the group ( p= 0.003, z= -2.972).

The extent of improvement in MAL (HWS) score in
experimental group is more as compared to conventional group
from pre test measurement to post test measurement as depicted
in [Graph-2].

Graph 2: Mean change in MAL (HWS) score between groups

There was a significant difference in score of MAL
(HWS) from pre to post in conventional group (p= 0.002, z =
-3.062) and in experimental group (p= 0.001, z= -3.408).

There was statistically significant difference in the
change score in MAL (HWS) between the groups (p= 0.005, z=
-2.825). The extent of improvement in ARAT score in experimental
group is more as compared to conventional group from pre test
measurement to post test measurement as depicted in [Graph- 3].

Graph 3: Mean change in ARAT score between

There was significant change from pre to post score
of ARAT in conventional group (p= 0.001, z= -3.190) and in
experimental group (p= 0.001, z= -3.411).

Mann-Whitney U test showed that there is statistically
significant difference in the change score in ARAT between the
groups (p= 0.001, z= -3.371).

Discussion

Overall result of the study shows that improvement in
hand function was found in both experimental and conventional
group as measured by Motor Activity Log (MAL) and Action
Research Arm Test (ARAT), however experimental group showed
significantly more improvement than conventional group,
providing Mirror Therapy with conventional treatment is more
effective than conventional treatment alone. Both the groups
(experimental group and conventional group) participated in the
conventional stroke rehabilitation program.

In this study there was improvement in MAL from
pre to post measurement after 4 weeks of intervention in both
experimental and conventional group. The Motor Activity Log
(MAL) consisted of Amount Scale (AS) which represents the
amount of use of the affected upper extremity and How Well
Scale (HWS) represents the quality of movement of the affected
extremity during the functional activity. The conventional group
showed 98.54% increase in Amount Scale (AS) scale and 26.24%
increase in How Well Scale (HWS).

There was improvement in object manipulation and task
related hand function. The improvement in conventional group
could be due to improved motor conventional and functional
recovery as Conventional exercises are linked to improve cortical
reorganization. Nudo RJ and Plautz EJ et al have demonstrated
in animal study that task-specific training can restore function
by using non-affected parts of the brain which are generally
adjacent to the lesion and/or recruiting supplementary areas of
the brain [19,20]. Using focal transcranial magnetic stimulation
(TMS) has shown that TSE, in comparison to traditional stroke
rehabilitation, yields long-lasting cortical reorganization specific
to the corresponding areas being used [21]. Patients in this group
practiced repeated meaningful tasks by affected UL. Some
researcher like Bayona NA and Byl et al has demonstrated that
rehabilitation may be more successful if the tasks and stimuli are
important and meaningful to the person [22,23].

It has been shown in various studies previously that
task-oriented training can result in improved hand function after
stroke.

Chanuk Yoo et al (2015) examined the improvement
of hand function and activities of daily living in stroke patients
after carrying out task-oriented training for 30 min per day for
4 weeks. Their hand function and activities of daily living were
evaluated before and after the training. They found that the task
oriented training had a significant impact in terms of improving
hand function and activities of daily living [24].

Jang, Sung Ho et al (2003) investigated the effect of
task oriented training on cortical activation pattern in 4 chronic
hemiparetic stroke patients. The functional status of the affected
hand and functional Magnetic Resonance Imaging (fMRI) were
assessed before and after the task oriented training program.
fMRI were performed parallel with timed finger flexion-extension
exercises at a fixed rate and concluded that cortical reorganization
was induced by the task oriented training program in chronic
hemiparetic stroke patients [25].

In experimental group of Motor Activity Log (MAL),
there was 138.70% increase in Amount Scale (AS) scale and
56.93% increase in How Well Scale (HWS). The subjects in
experimental group received an additional Mirror therapy
program. During the session subjects were asked to try to do the
same movements with the paretic hand while they were moving
the non-paretic hand. The subjects had done several exercises of
forearm, wrist and fingers.

There was improvement in object manipulation
and hand function with improved activity of daily living. The
improvement in experimental group could be due to the mirror
illusion. The experimental group received Mirror Visual Feedback
(MVF). Mirror visual feedback (MVF) might accelerate recovery
from hemiparesis by activating Mirror neurons found in frontal
as well as parietal lobe. The effect of mirror visual illusions on
brain activity investigated. Mirror neurons discharge with both
action observation and action execution. It has been proposed
that the mirror neuron system is instrumental in motor learning.
The human primary motor cortex (M1) displayed mirror activity
in response to movement observation, and is capable of forming
motor memories, and is involved in motor learning Katja
Stefan et al (2005). Another researcher also performed TMS
during mirror illusions in healthy subjects and found increased
excitability of primary motor cortex (M1) of the hand behind the
mirror [26].

It has been shown in various studies previously that
Mirror therapy can result in improved hand function after stroke.

Provided a case report using mirror therapy (MT) in
the home environment [27]. A home-based MT program was
practiced over 5 week. An independent evaluator administered
three outcome measures pre- and post intervention: Upper
Extremity Sensory and Pain sections of the Fugl-Meyer
Assessment; Jebsen–Taylor Test of Hand Function, and the Manual
Ability Measure–20. Change scores indicated improvement on all
of the included outcome measures. Hence they concluded that
a predominantly self-administered home-based MT program is
feasible and effective at improving function after stroke.

Used Transcranial Magnetic Stimulation (TMS) to look
at excitability of the motor cortex ipsilateral to a moving hand
in Motor Activity Log (MAL) subjects [28]. They studied four
conditions: (i) subjects watching the hand they were moving; (ii)
subjects watching their inactive hand; (iii) subjects watching a
marked position between the moving and inactive hand; and (iv)
subjects watching the reflection of the moving hand in a plane
reflecting mirror. They found a significant increase in motor
cortex excitability in the mirror viewing condition compared
with the other conditions consistent with the mirror reflection
exciting the motor cortex corresponding to the reflection of the
moving hand.

In experimental group of Motor Activity Log (MAL),
there was 40.16 % more increase in Amount Scale (AS) scale and
30.69% more increase in How Well Scale (HWS) than conventional
group. Following may be the reasons why experimental group
showed more improvement than the conventional group.
Suggested that the mirror illusion of a normal movement of
the affected hand may substitute for decreased proprioceptive
information, thereby helping to recruit the premotor cortex and
assisting rehabilitation through an intimate connection between
visual input and premotor areas [29]. This mirror illusion was
absent in conventional group of our study and therefore showed
less improvement as compared to experimental.

Results similar to the present study were reported
by Gunes Yavuzer et al [29]. They found that hand function
improved more after MT in addition to a conventional
rehabilitation program as compared with a conventional
treatment immediately after 4 weeks of treatment.

Other similar study was done by Ertelt et al., 2007 who
worked on stroke recovery using Mirror Visual Feedback (MVF),
except they had patients watch videos of movements performed
by healthy individuals presented via a screen in frontal view, and
then have the subjects try to use their paretic arm to make similar
movements [30]. This method of therapy was found in a Motor
Activity Log (MAL) trial to be superior to a conventional group of
subjects who received conventional physical therapy and watched
videos of geometric symbols. Many groups have also employed
virtual reality technology to create the visual feedback— instead
of using mirrors (Eng et al., 2007).

This result similar to our study showing that Mirror
therapy is helpful in improvement of hand function as assessed
by using MAL.

Conducted a randomized conventional trial to evaluate
the effects of mirror therapy on upper-extremity’ motor recovery,
spasticity, and hand-related functioning of inpatients with
subacute stroke [31]. The scores of the Brunnstrom stages for the
hand and upper extremity and the FIM self-care score improved
more in the mirror group than in the conventional group. Hence,
they concluded that the group of subacute stroke patients, hand
functioning improved more after mirror therapy in addition
to a conventional rehabilitation program compared with a
conventional treatment immediately after 4 weeks of treatment
and at the 6-month follow-up.

Our result similar to their study showed that Mirror
therapy in conjunction with conventional physiotherapy was
more helpful in improvement of hand function as compared to
conventional physiotherapy alone as assessed by using MAL.

Action Research Arm Test (ARAT)
The Action Research Arm Test (ARAT) is an assessment
tool used to identify the functional improvement of an upper
limb’s performance ability. It sub-items include holding (six
items), grasping (four items), picking up (six items), and total
movements (three items). The total score for these 19 items is 57,
and a higher score is associated with a higher performance level.
In this study there was improvement in ARAT from pre to post
measurement after 4 weeks of intervention in both experimental
and conventional group. The conventional group showed 56.01%
improvement in ARAT.

The subjects in conventional group received
conventional therapy consisted of similar exercise as described
earlier. Each task was practiced for 30 repetitions for 5 days in a
week for 4 weeks. There was improvement in object manipulation
of different shapes and sized objects. The result could be due to
improved motor conventional (due to repetitive task training)
and functional recovery as Conventional exercises are linked to
improve cortical reorganization.

Most researchers recommend that the more the task is
practiced, the better the overall performance [31,32].

According to Kilgard and Merzenich repetition plays a
major role in inducing and maintaining brain changes [33].

In another study by Richards LG et al who demonstrated
Neural plastic changes in the human brain following stroke and
task specific intervention [34]. Another scientist Jang SH et al.
noted decrease in the unaffected and an increase in the affected
primary sensorimotor cortex activities along with functional
recovery in stroke patients who received TSE [35]. It has been
shown in various studies previously that task-oriented training
can result in improved hand function after stroke.

Examined the improvement of hand function and
activities of daily living in stroke patients after carrying out task
oriented training [24]. Their hand function and activities of daily
living were evaluated before and after the training. They found
that the task-oriented training had a significant impact in terms
of improving hand function and activities of daily living.

In experimental group there was 124.6% increase from
pre to post measurement in Action Research Arm Test (ARAT).

The subjects in experimental group received Mirror
therapy. The subjects done similar exercises of forearm, wrist and
fingers as mentioned above. There was improvement in object
manipulation of different sized objects (blocks, ball) and hand
function with improved activity of daily living. The improvement
in experimental group could be due to activation of mirror
neuron system triggered by the observation of mirror illusion
explained by Franceschini M , Dushanova J et al . Mirror neurons
discharge not only during action execution but also during action
observation [36-38]. The discharge of these neurons is associated
with object-oriented hand actions such as grasping, holding,
tearing, and manipulating [39,40]. These areas are rich in motor
command neurons each of which fires to orchestrate a sequence
of muscle twitches to produce simple skilled movements [41].
These cortical areas are supposed to be activated by MT which
suggests that they might be involved in the efficacy of MT in
stroke [39,42]. It has been shown in various studies previously
that Mirror therapy can result in improved hand function after
stroke.

Conducted a study on 36 stroke subjects and were
divided into MT and conventional group [43]. The main outcome
measures were the Fugl-Meyer sub scores for the upper extremity,
FIM and ARAT. This study demonstrated that application of MT
in the early phase after stroke resulted in functionally relevant
improvements in motor, sensory and attentional deficits and to
support motor recovery in a distal plegic limb.

Evaluated the effect of MT on upper limb motor recovery
and motor function in 26 subacute stroke subjects [44]. The FMA,
Brunnstrom motor recovery stage, manual function test were
used as an outcome measures. They found that there were great
improvement in the score of Brunnstrom recovery stage, manual
function test of hand in experimental group and also there was no
significant difference in coordination items of FMA.

Studied to evaluate for any clinical effects of home
based mirror therapy and subsequent cortical reorganization
in patients with chronic stroke with moderate upper extremity
paresis [45]. The primary outcome measure was the Fugl-Meyer
Motor Assessment (FMA). Changes in neural activation patterns
were assessed with functional Magnetic Resonance Imaging
(fMRI). Result showed Post treatment, the FMA improved more
in the mirror than in the conventional group fMRI results showed
a shift in activation balance within the primary motor cortex
toward the affected hemisphere in the mirror group only.

In experimental group there was 67.99% more increase
in Action Research Arm Test (ARAT) as compared to conventional
group.

Following may be the reasons why experimental group
showed more improvement than the conventional group. Within
stroke patients, the sensomotoric coupling is often disturbed,
which might compromise task-intrinsic feedback [46]. Therefore,
to recover motor function stroke patients may be more dependent
on augmented feedback [47]. This augmented feedback might be
delivered in the form of visual feedback through MT [48]. This
augmented feedback was absent in conventional group of our
study because they did not practice with the mirror. This might
have contributed to more improvement in experimental group as
compared to the conventional group.

Another possible mechanism for effectiveness of mirror
therapy might be bilateral arm training. Bilateral arm training
was not practiced by subjects of conventional group as they
performed exercise by using unilateral hand (Muzaffar Tufail et
al).

Results similar to the present study were reported
by Sneha S. Khandare et al [49]. They found that hand
function improved more after MT in addition to a conventional
rehabilitation program as compared with a conventional
treatment immediately after 4 weeks of treatment.

Kyunghoon Kim et al (2016) investigated the effects
of mirror therapy combined with exercise tasks on the function
of the upper limbs and activities of daily living [50]. Upper limb
function was measured with the Action Research Arm Test
(ARAT), the Fugl-Meyer Assessment, and the Box and Block test
and activities of daily living were measured with the Functional
Independence Measure (FIM). They found that in the intragroup
comparison, both groups showed significant differences between
measurements taken before and after four weeks of therapy. In
the intergroup comparison, the mirror therapy group showed
significant improvements compared with the conventional
therapy group, both in upper limb function and activities of daily
living. Hence, concluded that the mirror therapy is more effective
than conventional therapy for the training of stroke patients to
improve their upper limb function and activities of daily living.

Invernizzi M et al (2013) did a randomized
conventional trial to evaluate adding mirror therapy (MT) to
conventional therapy (CT) can improve motor recovery of the
upper limb in subacute stroke patients [51]. Action Research
Arm Test (ARAT) was the primary outcome measures. Motricity
Index (MI) and the Functional Independence Measure (FIM)
were the secondary outcome measure. After one month of
treatment patients of both groups showed statistically significant
improvements in all the variables (P< 0.05). Moreover patients of
the MT group had greater improvements in the ARAT, MI and FIM
values compared to CT group (P< 0.01), Glass’s.

Our result similar to their study showed that Mirror
therapy in conjunction with conventional physiotherapy was
more helpful in improvement of hand function as compared to
conventional physiotherapy alone as assessed by using ARAT.

Small sample size, No follow-up study was performed,
Participants of single geographic location.

Clinical Utility

Mirror therapy can be used simultaneously in clinical
as well as home based setting to bring about improvement in
hand function. Also, the cost effectiveness and easy applicability
seems to make mirror therapy a useful adjunct to conventional
physiotherapy.